Improving Lab Reports

As lab medicine grows more complicated and busy physicians have less time to review and interpret test results, many experts have called for improved lab reports that employ graphics and layout to improve physicians' understanding of results. This issue of Strategies explores a recent study that examined how physicians made use of enhanced graphical reports.

A limited number of studies have shown that improved formatting and templates can boost the quality of lab reports, but not many have evaluated physicians' use of enhanced reports or the impact of these reports on care management and outcomes. Recently, researchers at ARUP Laboratories examined how often clinicians took advantage of enhanced graphical reports available online (J Pathol Inform 2012;3:26). The research follows-up on a pilot project ARUP began in 2009 that gives clinicians access to special supplemental reports for certain tests. For the most part, such reports could not otherwise be transmitted using current lab information systems and electronic health records (EHRs). For physician access, ARUP offers a link and passcode in the footnotes of the standard version of results for these tests.

The researchers looked at how often clinicians downloaded enhanced reports for 48 tests over a period of 22 months, paying attention to which reports were downloaded most and the download rates for normal versus abnormal results. Of the 48 tests with enhanced reports, five were genomic microarrays, six were maternal screening tests, and 24 were molecular cytogenetic tests. Another 13 varied tests included HIV-1 genotyping, oxycodone and opiate confirmations, low-density lipoprotein subclasses, and hepatic copper concentration.

The researchers found an unexpectedly low overall rate of downloads. The median download rate by test was 8.6%, with large variations among tests. For example, maternal screening tests had one of the lowest median download rates, at 4.4%, even though these tests made up 64% of the total report downloads. In contrast, many of the lower-volume tests had high rates of enhanced report download, such as nearly 65% for oxycodone confirmation and 53% for BCR-ABL1 gene testing. Notably, enhanced reports were downloaded 8% more often for abnormal results versus normal results across the board.

Although they had expected higher rates of downloads, the researchers were not completely surprised, given the difficulty in getting such reports into clinicians' hands, said Brian Jackson, MD, an author of the study. "I'd certainly hoped that we'd find physicians were downloading these reports in higher volumes," he said. "On the other hand, downloading these reports requires several additional steps for physicians that are not part of their routine of reviewing results."

While ARUP's lab clients have more straightforward access to the enhanced reports via the organization's online report retrieval system, physicians would have to take the initiative to follow the instructions in the footnote of standard result reports and then retrieve the enhanced reports online, he added. Jackson is vice president and chief informatics officer at ARUP Laboratories, and medical director for referral testing, and an associate professor of pathology at the University of Utah in Salt Lake City.

According to Jackson, the study demonstrates the barriers inherent in what he described as a very limited and outmoded data model for sharing results with clinicians. "We're really stuck with a 30-year old data model for how to send our laboratory results. A lab result is either a number or a short alphanumeric combined with units, reference intervals, and a plain text box for comments. This allows for few subtleties of communication."

For the most part, lab coding schemes such as HL7—on which electronic health records (EHR) are built—offer little help in this regard, Jackson said. "Trying to send highly esoteric laboratory results such as genomics using the current system is sort of like trying to publish a magazine entirely on Twitter: it's extremely limiting and you end up losing the ability to communicate clearly. To me, that's broken."

While EHRs provide users with some flexibility in formatting lab reports, so far the evidence is lacking that this flexibility leads to improved care, said Paul Valenstein, MD, who has written about improving pathology reports. "More flexibility doesn't necessarily mean increased comprehension or an increased likelihood that the reader of the report will take the correct course of action. In fact, flexibility can introduce problems," Valenstein said. "Frequently, formatting becomes corrupted as results pass from one information system to another, and a beautiful report emanating from a lab can wind up looking horrible when displayed on someone's electronic medical record system." Valenstein, who was not associated with the study, is president of Joint Venture Hospital Laboratories and pathology division head of Pathology and Laboratory Management Associates in Ann Arbor, Mich.

Paradoxically, the increased emphasis on transmitting lab data as discrete elements rather than formatting text leaves more room for recipient systems to alter formatting and less control by the lab producing the report, Valenstein noted. "It's way too early to conclude that EHRs will improve comprehension. There will be more formatting options, but whether they'll be applied properly remains to be seen."

Jackson, an influential thought leader and expert on lab informatics, has a lot of ideas about how to fix the current data sharing structure—not for abandoning traditional systems, but building in new options. "Our goal is not to bypass HL7-formatted field defined laboratory data. The goal is to supplement it. Think of the Internet as a paradigm. The reason that the Internet took off so rapidly as it did in the mid-1990s had a lot to do with the fact that the first major standard for the Internet was HTML, which is not a data standard: it's a visual layout standard. The Internet was designed to be user-friendly before it was designed to be data-friendly. In our case, LIS and HL7 interfaces are data standards, not human-friendly standards."

As is the case with HTML, Jackson would like to see two layers of data sharing standards for lab results: a human-friendly standard that includes graphics and layout on one level, and a parallel layer that carries field-defined structured data behind the scenes. Something similar already exists for other kinds of test results, such as electrocardiograms (EKG), Jackson added. For example, at the University of Utah Hospital, the EHR carries EKGs in two formats: the textual interpretation format, and next to it the graphic file that shows the actual tracing. In the short-term, labs will likely work toward something similar, integrating hyperlinks to PDFs of enhanced reports via text in traditional lab reports.

Given the current challenges in providing enhanced reports to physicians, and the uncertainty around how physicians will use them, Jackson urged caution for individual labs considering investing resources in developing enhanced reports. Valenstein agreed, and advised that enhanced reports should be reserved for solving specific communication problems. "While awareness of communication science is slowly growing, I believe we're still in an era where people equate their personal preference with good design. Report designers don't rigorously test whether communication is enhanced by graphical elements or other formatting techniques," Valenstein said. "One area where highly controlled experiments have shown that graphical elements improve communication is in the transmission of two-dimensional data. Information in a scatterplot or a line graph is much more easily absorbed than the same data presented in a tabular format. But most lab data are not two-dimensional. As the authors of the study suggest, I would be cautious about investing a lot of energy to produce graphics when there isn't a particular communication challenge that is better addressed by graphics."